Heart failure survival among older adults in the United States: a poor prognosis for an emerging epidemic in the Medicare population.

OBJECTIVE: To describe the 6-year probability of survival for older adults after their first hospitalization for heart failure. SETTING: National Medicare hospital claims records for 1984 through 1986 and Medicare enrollment records from 1986 through 1992. DESIGN: We identified a national cohort of 170 239 (9% black patients) Medicare patients, 67 years or older, with no evidence of heart failure in 1984 or 1985, who were hospitalized and discharged for the first time in 1986 with a principal diagnosis of heart failure. For groups defined by race, sex, age, Medicaid eligibility, and comorbid conditions, we compared the probability of survival with Cox proportional hazards regression. RESULTS: Only 19% of black men, 16% of white men, 25% of black women, and 23% of white women survived 6 years. One third died within the first year. Men had lower median survival and 38% greater risk of mortality than did women (P<.05). White men had 10% greater risk of mortality than did black men (P<.05). Medicaid eligibility (white adults only) and diabetes were associated with increased mortality (P<.05). CONCLUSIONS: The prognosis for older adults with heart failure underscores the importance of prevention strategies and early detection and treatment modalities that can prevent, improve, or reverse myocardial dysfunction, particularly for the growing number of adults who are at increased risk for developing heart failure because of hypertension, diabetes, or myocardial infarction.

Clinical assessment of the single use laryngeal mask airway--the LMA-unique.

We conducted a clinical comparison of the laryngeal mask airway (LMA) and the new single use PVC LMA (LMA-Unique) in 100 fasted adult patients undergoing elective surgery. Patients were allocated to one of two groups: group 1 (n = 50) was managed by two consultants and group 2 by two trainee anaesthetists. Airway management was randomized prospectively within each group, and cuff pressure in both devices was maintained at a maximum of 50 mm Hg with upward size substitution if leaks persisted during intermittent positive pressure ventilation (IPPV). Insertion with the recommended technique was successful in all patients (85 first attempt). One patient (group 1) required four attempts for insertion of the LMA-Unique and in one patient (group 2) the LMA-Unique was replaced by a tracheal tube because of persistent leaks during IPPV. In 99 patients IPPV was uneventful. The adjusted mean volume of air for cuff inflation in the LMA-Unique was significantly less in group 1 (P = 0.0013). At fibreoptic laryngoscopic examination, the vocal cords or arytenoids, or both, could be seen in 92% of patients in group 1 and in 90% of patients in group 2. Immediate throat soreness was reported in four patients in group 1 and in seven in group 2. The results suggest that the LMA-Unique was similar in clinical performance to the LMA.

National trends in the initial hospitalization for heart failure.

OBJECTIVES: Heart failure is a major health care burden among older adults, but information on recent trends has not been available. We compare rates, sociodemographic characteristics, and discharge outcomes of the initial hospitalization for heart failure in the Medicare populations of 1986 and 1993. DESIGN: Information reported on the Medicare hospital claims record during initial hospitalization for heart failure was compared for patients aged 65 and older hospitalized in 1986 (N = 631,306) and those aged 65 and older hospitalized in 1993 (N = 803,506). RESULTS: Age-standardized hospitalization rates (per 1000 person-years) for any diagnosis of heart failure were higher in 1993 than in 1986 (white: 24.6 vs 22.4, black: 26.1 vs 22.4, respectively). Age-specific results suggested an earlier onset of heart failure in black adults. In 1993, compared with 1986, higher proportions of heart failure patients were discharged to another care facility (white: 23.9% vs 16.8%, black: 17.6% vs 10.5%, respectively) or to health service care at home (white: 11.3% vs 6.0%, black: 12.4% vs 6.5%, respectively). In contrast, in-hospital mortality was lower in 1993 than in 1986 (white: 10.4% vs 13.3%, black: 8.9% vs 11.1%, respectively). CONCLUSION: The increased numbers of hospitalizations for heart failure and the likelihood that these patients will require advanced nursing care after discharge have important implications for future national health care expenditures and resources.

Malpractice litigation against child and adolescent psychiatry residency programs, 1981-1991.

A national survey was conducted to investigate malpractice litigation at United States child and adolescent psychiatry residency programs between 1981 and 1991. Fourteen percent of the directors of child and adolescent psychiatry reported at least one malpractice claim during this period. The highest percentage of lawsuits reported was in the northeast. Suicide and sexual abuse of latency age patients by other patients accounted for the most litigation. The mean monetary award was $167,000, and the largest award was $500,000 for discharge of a patient who killed his mother. There has been an increase in malpractice litigation during the past 10 years. Risk management strategies should be implemented to address areas of liability in child and adolescent psychiatry training programs.

Disseminated herpes zoster in the immunocompromised host: a comparative trial of acyclovir and vidarabine. The NIAID Collaborative Antiviral Study Group.

Seventy-three immunocompromised patients with disseminated herpes zoster were evaluated in a double-blind controlled trial of acyclovir (n = 37) versus vidarabine (n = 36) therapy. Acyclovir was administered at 30 mg/kg/day at 8-h intervals and vidarabine was given as a continuous 12-h infusion at 10 mg/kg/day for 7 days (longer if resolution of cutaneous or visceral disease was incomplete). No demographic differences existed between treatment groups. No deaths attributable to varicella-zoster virus infection occurred within 1 month of treatment. Neither rates of cutaneous healing, resolution of acute neuritis, and frequency of postherpetic neuralgia nor adverse clinical and laboratory events differed between treatment groups. Acyclovir recipients were discharged from the hospital more promptly than vidarabine recipients (P = .04, log rank test). These data indicate that disseminated herpes zoster is amenable to therapy with either acyclovir or vidarabine; resultant mortality is low.

Assessment of the presence of cytomegalovirus-neutralizing antibody by a plaque-reduction assay.

Evaluation of the in vitro neutralizing activity of 30 immunoglobulin G (IgG) preparations and seven batches of pooled plasma against human cytomegalovirus (CMV) was performed by plaque-reduction assays. There were definite differences detected by these methods that could permit the selection of preparations with highest titers for clinical trials. The addition of guinea pig complement to the plaque-reduction assay enhanced inhibition of CMV; thus, guinea pig complement should be used in assays of IgG preparations. There was no relationship between the ELISA-derived optical density values of the IgG samples and the titers determined by plaque neutralization. These data suggest that the results of plaque-reduction neutralization assays provide important information about preparations of antibody that may be selected for patient administration. The preparations selected for their high titers by neutralization assays differ significantly from those identified by another method.

The risk of acquiring hepatitis from sewage-contaminated water.

There is little information on the risk of acquiring hepatitis A from drinking sewage-contaminated water. In a large outbreak of gastrointestinal illness at Crater Lake National Park, Oregon, a US national park, in June-July, 1975, approximately 100,000 persons were exposed to sewage-contaminated water. State health departments reported three cases of Crater Lake-associated hepatitis A for a rate of 12/100,000 per year, comparable to the reported US incidence of non-B hepatitis 10/100,000 per year. Questionnaire survey of 3997 overnight park visitors revealed five cases of hepatitis A, occurring in 2206 persons who drank water but did not receive immune serum globulin (ISG) within two weeks of exposure, an attack rate of 0.23%. The association between drinking park water and subsequently developing hepatitis was not statistically significant. No cases of hepatitis occurred in 320 park staff and family members, repeatedly exposed to contaminated water. The authors do not recommend routine use of prophylactic ISG for similar outbreaks of gastroenteritis caused by sewage-contaminated water but suggest close surveillance of the exposed group, and careful consideration of risk factors and costs.

Acute water shortage and health problems in Haiti.

During a severe drought Port-au-Prince, Haiti, lost hydroelectric power for 10 weeks. This led to water shortages in areas of the city dependent on water supplied from electrically driven pumps. In a study of the impact of water restriction on disease, 400 families were randomly selected from two urban areas differentially affected by the water shortage. Disease in children was found to be related to quantity of water used, socioeconomic status, employment of head of household, and family size. The methods used in this study are recommended for the investigation of the relationship between water quantity and health.

Vaccination against influenza: a five-year study in the Post Office.

An injection of influenza vaccine was offered to approximately 60 000 Postal and Telecommunications staff at the beginning of five successive winters. The sickness absence of this group, which included those who accepted the offer of vaccine as well as those who did not, was compared throughout the winter with that of a similar number of employees who were not offered vaccine. The two groups, ;vaccinated' and control, comprised the staff of nearly 400 Post Office units scattered throughout Great Britain, the units of the two groups being matched as far as practicable for numbers employed, type of work, region and type of location.The proportion who accepted vaccine fell from 42% in the first year (when only 26 000 Telecommunications employees were offered vaccine) to 35% in the second year, and 25% by the fifth year.With the exception of Telecommunications employees in 1972-73, the sickness absence rate of the group offered vaccine was less than that of the group not offered vaccine, and the difference was evident during the winter observation periods both when influenza was prevalent and when it was not. In the last four years of the study the average difference in sickness absence between the ;vaccinated' and control groups was 1.26 days per 100 employees per week during and 1.12 days outside the influenza periods. Moreover, the difference during the influenza periods was greater than could be expected from the acceptance rate of vaccine and the estimated attack rate of influenza. The apparent reduction in sickness absence of the group offered vaccine in comparison with the group not offered vaccine represented an appreciable saving in cost.It is suggested than an annual influenza vaccination campaign in industry may produce financial benefit, but that only a proportion of the benefit is due to an improvement in health.